Shoulder Pain Through Exercise: The Activation and Imbalance of the - PowerPoint PPT Presentation

Evidence Based Approach to Addressing Shoulder Pain Through Exercise: The Activation and Imbalance of the Upper Trapezius, Lower Trapezius, and the Serratus Anterior z Gretchen Paulson, MS, ATC

z OBJECTIVES Understand the role Identify evidence Implement these of the scapulothoracic based exercises that exercises in force couple and the restore muscular everyday relationship to shoulder control and balance of rehabilitation injury the UT, SA, LT practice

z z Prevalence of Shoulder Pain  Shoulder pain is a pervasive complaint associated with overhead athletes  Interfering shoulder pain has been reported in up to 87% of swimmers at some point throughout their career (Pink et al. 2000, Madsen et al. 2011)  Incidence of shoulder injuries in overhead athletes occur 1.8/1000 hours (Asker et al. 2017)

z Prevalence of Shoulder Pain  Shoulder pain is also one of the most common complaints among the general population  It is the third most common musculoskeletal complaint in orthopedic practice (Garving et al. 2013)  60% of the population complain of shoulder pain at some point in their life ( Cools et al. 2013)

z Long periods or sitting and computer use can lead to altered scapular resting position resulting in shoulder and neck pain Cools et al. 2013

z Anatomy Subacromial Space  Borders:  humeral head  anterior acromion process  coracoacromial ligament Width: 1.0 – 1.5 cm   Structures:  Subacromial bursa  Supraspinatus tendon  Capsule  Long head of the biceps

z z Muscular Anatomy F DELT F INF  17 muscles attaching to the RA shoulder complex F SUB  Force couples allow for coactivation of the dynamic stabilizers in order to centralize F TM the humeral head and allow for normal scapular kinematics

z Muscular Anatomy

z Etiology  Shoulder pain can stem from a variety of pathologies including subacromial impingement syndrome, rotator cuff tears, labral injuries, and multidirectional instability  The more chronic injuries often stem from overuse, heavy training load, hypermobility of the shoulder, and altered scapular mechanics  The evidence of scapular dyskinesis present in those who complain of shoulder pain is substantial ( Ludwig et al. 2009, Kibler et al. 2010)

z Scapular Dyskinesis and Shoulder Pain Reported in 68% of patients with rotator cuff injuries Reported in 94% of patients with labral lesions Reported in 100% of patients with glenohumeral instability (Ludwig et al. 2009, Kibler et al. 2010, Carbone et al. 2015)

z Normal Scapular Kinematics During humeral elevation: scapular upward rotation, external rotation and posterior tilt should occur

z z Scapular Dyskinesis The alteration of normal scapular kinematics Three different types: Type I = Inferior angle prominence Type II = Medial border prominence Type III= Excessive superior border elevation

z Scapular Dyskinesis SICK Scapula • Scapular malposition • Inferior medial border prominence • Coracoid pain and malposition • Dyskinesis Burkart et al. 2003

z z Forward Head Posture  Tightness in levator scapulae  Decreased upward rotation  Decreased posterior tilt Ludewig et al. 2000

z Rounded Shoulders  Tightness of pectoralis major and minor  Weakness in middle and lower trapezius

z z Scapular Dyskinesis and Subacromial Space  Alterations in scapular kinematics often lead to a narrowing of the subacromial space (Paine et al. 2013, Ludewig et al. 2000, Kamkar et al. 1993)  The most common scapular dysfunctions implicit with decreased subacromial space are excessive anterior tilt and reduced upward rotation ( Ludewig et al. 2000, Michener et al. 2003)  Any reduction in the subacromial space can lead to a host of shoulder pathologies

z Dysfunction in Overhead Athletes  Swimmers often present with forward head posture, rounded shoulders, and static and dynamic scapular positioning congruent with SICK scapula (Madsen et al. 2011)  82% of swimmers without shoulder pain presented with scapular dyskinesis after one training session (Madsen et al. 2011)  Abnormal scapular position is seen with excessive protraction during cocking and early acceleration of the throwing phase (Burkhart et al. 2000)  Associated with labral tears, internal impingement, and elbow injuries in throwing athletes (Burkhart et al. 2003)

z  One potential cause of scapular dyskinesis is imbalance or altered muscular activity patterns within the scapulothoracic stabilizers  The muscular imbalance of the force couple existing between the upper trapezius, lower trapezius, and serratus anterior is a common focus throughout the literature

z z Scapulothoracic Stabilizers  Serratus anterior (SA), upper trapezius (UT), and lower trapezius (LT) produce upward rotation and provide stability for the scapula  During humeral elevation, the LT also assists in posterior tilting of the scapula, while the SA produces protraction

z  Scapulothoracic Some research attributes scapular dyskinesis to overall strength deficits; Stabilizers: however, it is important to look at the imbalance of these muscles as they work as Strength or a force couple Balance?  It has been seen noted that inhibition of the LT and SA is often combined with excessive activation of the UT in those with subacromial pain syndrome (Cools et al. 2007, Ludewig et al. 2000, Michener et al., 2016)  When designing rehabilitation to address these issues, it is important to target the muscles that are inhibited, while minimally activating those that are hyperactive

z SA and LT Strength and Subacromial Space   Bdaiwi et al. placed neuromuscular Timmons et al. measured electrical stimulation on the LT and SA subacromial space width muscles to stimulate a contraction before and after a lower while simultaneously observing the trapezius fatigue protocol subacromial space via diagnostic  Subacromial space decreased ultrasound at 45º of arm elevation following the fatigue protocol  found an increase in subacromial space with combined stimulation to the LT and SA  Signifies the important role these muscles play in the opening of the subacromial space.

z Rehabilitation Strategies  The relationship between scapular dyskinesis, scapulothoracic muscle imbalance and shoulder pain is well established in the literature  Rehabilitation must address the present dysfunctions  When dyskinesis is identified, It is essential to focus on exercises that restore neuromuscular control and the balance of the UT, LT, and SA

z z Rehabilitation Strategies When scapular dyskinesis is present, it is important to distinguish between strength deficits, imbalances, or flexibility/tissue length (Cools et al. 2013)

z Activation Exercises Serratus Anterior Wall Slides Standing Scaption Push-up Plus Hardwick et al. 2006 Hardwick et al. 2006, Reinold 2009 to 120º Ekstrom et al. 2003, Hardwick et al. 2006

z Activation Exercises Serratus Anterior Scapular Punches Dynamic Hug Inferior Glides Ekstrom et al. 2003 Ekstrom et al. 2003, Reinold 2009 Kibler et al. 2008

z Activation Exercises Lower Trapezius Scaption to Prone Ts with Prone Ys 120º Ekstrom et al. 2003 external rotation Ekstrom et al. 2003 Ekstrom et al. 2003

z Activation Exercises Lower Trapezius Prone shoulder external Prone Extension Cools et al. 2007 rotation at 90º abduction Ekstrom et al. 2003

z Balance of the UT/LT  Forward flexion in a side-lying position  Side lying external rotation  Prone horizontal abduction with ER (Ts) Cools et al. 2007

z Balance of the UT/LT Shoulder elevation with resisted ER  High LT/MT activation with lower UT Casteleine et al. 2016

z Balance of UT/SA  Scapular punches  Push-up plus  Inferior glides

z A balancing act Not all exercises with the best quality activation are also ideal for UT/LT/SA balance What are your goals? Neural Activation? Strength? Restore coactivation? Stage of Rehabilitation

z z Rehabilitation Strategies (Cools et al. 2013)

z Rehabilitation Strategies  Exercises for early stages of rehabilitation  Inferior glide  Side-lying ER  Prone extension  Scapular punches

z Rehabilitation Strategies  Exercises for middle to late rehabilitation stages  Prone shoulder external rotation with 90º abduction  Prone Ys  Push-up plus  Wall Slides*

z A study that looked at the effect of a 4-week strengthening intervention program, specifically targeting the lower trapezius and serratus anterior muscles, on scapular upward rotation, forward shoulder posture, and subacromial distance in collegiate swimmers

Intervention group: Baseline 4-Weeks 4-week SA/LT -Upward rotation -Upward rotation strengthening -Subacromial space -Subacromial space program -Fwd shld posture -Fwd shld posture Control group: Baseline 4-Weeks Regular season -Upward rotation -Upward rotation practices and -Subacromial space -Subacromial space weight training -Fwd shld posture -Fwd shld posture